Healthcare Provider Details

I. General information

NPI: 1457444705
Provider Name (Legal Business Name): BERNARD JAMES COSTELLO MD, DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 TERRACE ST
PITTSBURGH PA
15261-0001
US

IV. Provider business mailing address

4190 MUIRFIELD CIR
PRESTO PA
15142-1069
US

V. Phone/Fax

Practice location:
  • Phone: 412-648-6801
  • Fax:
Mailing address:
  • Phone: 412-648-6801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDS029638L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: